Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

BACKGROUND: Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. AIM: To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. METHODS: Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. RESULTS: Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). CONCLUSIONS: Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Not Just Small Adults: Operative Versus Nonoperative Treatment in Adolescent Tibial Shaft Fractures.

BACKGROUND: The standard of care for tibial shaft fractures in young children is nonoperative management, while in adults, operative treatment is considered the mainstay. There are no clear guidelines on preferred treatment for adolescents. PURPOSE: This paper aims to 1) identify clinical and radiographic characteristics predictive of malalignment and 2) determine if treatment type affects malalignment risk. METHODS: This retrospective cohort study identified patients aged 12 to 16 years old with a tibial shaft fracture at a Level 1 pediatric trauma center. The primary outcome of interest was malalignment, classified as meeting one or more of the following: >5° coronal angulation, >5° sagittal angulation, translation (cortical width or 100% displaced), and/or rotational deformity. Comparative analyses were done to identify risk factors for malalignment. RESULTS: A total of 162 patients were included-initial treatment was "planned nonoperative" for 102 patients and "planned operative" for 60 patients. The malalignment rate was 34% in the planned nonoperative group versus 32% in the planned operative group. In a multivariate regression, older patients [odds ratio (OR)=-0.07, 95% CI: -0.13 to -0.01; P =0.024] and those with 100% initial displacement (OR=-0.35, 95% CI: -0.64 to -0.05; P =0.021) had decreased odds of malalignment, and having increased sagittal angulation (OR=0.02, 95% CI: 0.01-0.04; P =0.002) and a fibula fracture (OR=0.22, 95% CI: 0.03-0.41; P =0.023) increased the odds of malalignment. There was no difference in the rate of malalignment by initial treatment ( P =0.289). Having a planned nonoperative treatment (OR=22.7, 95% CI: 14.0-31.5; P <0.001) and having a fibula fracture (OR=8.52, 95% CI: 0.59-16.45; P =0.035) increased the time immobilized. CONCLUSIONS: This study provides insight into factors affecting tibial shaft fracture alignment among patients aged 12 to 16 years. This study suggests that the risk of malalignment is higher among patients with increased initial sagittal angulation and concomitant fibula fractures, but the risk of malalignment is comparable in patients initially treated nonoperatively and operatively. Although healing parameters on average were similar, nonoperative treatment results in longer immobilization time and time for unrestricted weight bearing. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Clinical Outcomes and Associated Pathologies Following Pediatric Traumatic Hip Dislocations: A Systematic Review of the Literature.

INTRODUCTION: Pediatric traumatic hip dislocations are a rare condition that can have devastating short and/or long-term outcomes and associated pathologies (APs), including associated injuries (AIs) and long-term adverse events (LTAEs), with negative long-term sequelae. Currently, there are little data that exist on the rate of APs, with the most notable being avascular necrosis (AVN), for pediatric traumatic hip dislocations. The purpose of this systematic review is to evaluate the outcome relative frequency of dislocation direction, reduction type, and rate of APs for traumatic hip dislocations in the pediatric population. METHODS: A systematic review on the topic of traumatic hip dislocations in the pediatric population was performed using PubMed, ScienceDirect, Web of Science, CINAHL, and MEDLINE databases from database inception to March 30, 2023. Inclusion criteria was full-text English articles, addressed traumatic hip dislocations, and pediatric patients (<18 y old). RESULTS: A total of 24 articles (n=575 patients) met final inclusion criteria from a total of 219 articles retrieved from the initial search. For the average age of the included patients with reported age (n=433 patients), the frequency weighted mean was 9.50 years±1.75 years with a frequency weighted mean follow-up time of 74.05 months ±45.97 months (n=399 patients). The most common dislocation direction was posterior (86.4%), the most common treatment type was closed reduction (84.5%), AVN was the most common type of LTAEs (15.5% of APs), and labral/capsular injuries and acetabular fractures were the most common type of AIs (14.0% and 9.4% of APs, respectively). There were a combined total of 414 APs (72%) out of 575 total patients. CONCLUSION: Pediatric traumatic hip dislocations are associated with a high rate of AIs and LTAEs (72%, 414 APs out of 575 patients). AVN, labral/capsular injuries, and acetabular fractures are the most common APs after pediatric traumatic hip dislocations. Pediatric hip dislocations are usually posterior and commonly managed through closed reduction. LEVEL OF EVIDENCE: III, Systematic Review.

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study.

BACKGROUND: Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study. METHODS: This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts. RESULTS: Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P<0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P<0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P=0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement. CONCLUSION: We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement. LEVEL OF EVIDENCE: II.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE: Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively. METHODS: We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups. RESULTS: Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts. CONCLUSIONS: For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients. LEVEL OF EVIDENCE: Level II-therapeutic studies: prospective cohort study.

An Analysis of Negative One-star Patient Reviews and Complaints for Pediatric Orthopaedic Surgeons throughout the United States: A Retrospective Study.

OBJECTIVE: Patients commonly use physician review websites when choosing a surgeon for an elective procedure. Although data exist regarding other orthopaedic specialties, no study has investigated one-star reviews for pediatric orthopaedic surgeons. The goal of this retrospective study was to classify the factors contributing to one-star reviews of pediatric orthopaedic surgeons to identify which areas contribute to lower patient satisfaction. METHODS: Patient ratings on a 5-star system and comments about pediatric orthopaedic surgeons were collected from the state with the most physicians registered in the "Pediatric Orthopaedic Society of North American" database for each of the 9 geographical regions of the United States as defined by the Association of American Medical Colleges. One-star reviews that included comments were classified as either surgical or nonsurgical. These comments were then further classified based on their content. RESULTS: Three hundred fifty-four one-star reviews with 700 complaints were included in this study. Of these complaints, 481 (68.7%) were from nonsurgical patients and 219 (31.3%) were from surgical patients. Nonsurgical patients were significantly more likely to reference the amount of time spent with the physician (12.9% to 6.6%, P = 0.026), wait time (11.9% to 0.0%, P < 0.001), and bedside manner (41.2% to 22.8%, P < 0.001). Patients who said they had undergone a surgical procedure in their one-star review were significantly more likely to reference a disagreement with the physician's decision or plan (35.3% to 17.5%, P < 0.001), and uncontrolled pain (21.6% to 5.2%, P < 0.001). There was no significant difference in the comments that referenced medical staff or institutional complaints between surgical and nonsurgical patients (13.8% to 11.4%, P = 0.424). CONCLUSION: Most one-star reviews of pediatric orthopaedic surgeons referenced interpersonal skills and other nonclinical aspects of a clinical encounter, with bedside manner being the most frequent complaint. Patients who had undergone surgical procedures were less likely to leave a one-star review, but if they did, their comment was usually about a disagreement with the physician's plan. CLINICAL RELEVANCE: Prognostic studies III.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Pediatric Diving-Related Injuries in Swimming Pools Presenting to US Emergency Departments: 2008-2020.

OBJECTIVES: Recreational swimming/diving is among the most common physical activities in US children and a significant cause of morbidity across the United States. This study updates the national epidemiology of diving-related injuries. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance System database was queried for patients aged 0 to 19 from 2008 to 2020 who presented to any of the 100 National Electronic Injury Surveillance System-participating emergency departments for a diving-related injury. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives. RESULTS: A total of 1202 cases were identified for analysis corresponding to a total national estimate of 37,387 diving related injuries during the period from 2008 to 2020 and a national incidence of 3.6 injuries per 100,000 population. Males accounted for 64% of injuries. The average yearly incidences of injury in the 10 to 14 and 15 to 19 age groups were identical at 5.8 per 100,000. Contact with the diving board or platform was the most common cause of injury (34%). Diving backwards or attempting a flip or handstand dive were associated with increased odds of sustaining an injury resulting from contact with the diving board or platform (odds ratio, 16.0 and 6.9, respectively). In 2020, the incidence of diving-related injury fell to 1.6 per 100,000 population. CONCLUSIONS: Diving injuries are common in children and adolescents, especially in boys aged 10 to 19. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

Evolution of total hip arthroplasty in patients younger than 30 years of age: A systematic review and meta-analysis.

INTRODUCTION: While surgical technique and implant technology for total hip arthroplasty (THA) has improved over the years, it is unclear whether recent progress has translated to improved clinical outcomes for young patients. The goal of this study is to determine trends in (1) indications, (2) surgical technique (3) clinical and radiographic outcomes, and (4) survivorship for THA in patients younger than 30 years of age. METHODS: MedLine, Cochrane, EMBASE, and Google Scholar were searched using several key phrases for articles focusing on THA performed on patients younger than 30 years of age between 1971 and 2020. A total of 34 qualifying articles were identified and stratified into three groups according to operative years and compared to one another on the basis of (1) indications; (2) fixation technique; (3) implant design; (4) clinical and radiographic outcomes; and (7) survivorship. RESULTS: The mean patient age at index THA were 20.5 (9-30), 22.1 (11-30) and 21.5 (10-30) years, respectively, for each study group. Over time, patients underwent fewer THAs for JRA (Juvenile Rheumatoid Arthritis) (p < 0.001) but more for post-treatment and iatrogenic avascular necrosis (p < 0.001; p < 0.001). Early THAs primarily used metal on UHMWPE (Ultra high molecular weight polyethylene) (71.7%, p < 0.001), modern THA predominantly use ceramic on HXLPE (Highly cross-linked polyethylene) (42.5%, p < 0.001). Early fixation methods used cement (60.4%, p < 0.001), and modern fixation primarily use press fit technology (95.9%, p < 0.001). Prevalence of radiographic loosening decreased significantly (p < 0.001) over time. There was no significant difference in clinical improvement on HHS. Lastly, fewer patients required THA revision in recent decades (p < 0.001). CONCLUSIONS: Advances in surgical technique and technology have served to improve implant longevity. Surprisingly, subjective clinical scores showed no significant improvement over time, suggesting that early iterations of THA were extremely successful.

Standardizing a Postoperative Protocol for Supracondylar Humerus Fractures.

BACKGROUND: Supracondylar humerus fractures are the most commonly operated upper extremity fracture in pediatric orthopaedics, yet there does not currently exist a standardized recommendation for a postoperative protocol. As advanced practice providers take on larger roles in the care of fracture patients, it may alleviate confusion to standardize postoperative protocols. The aim of this study was to compare outcomes between three different postoperative management protocols following operative fixation of supracondylar humerus fractures. METHODS: This is a retrospective study of all patients who underwent operative fixation of a supracondylar humerus fracture during the 2014 to 2015 academic year. Postoperative protocols were classified as either "liberal," "intermediate," or "conservative," based on how quickly the surgeon allowed unrestricted motion of the elbow postoperatively. Patients were evaluated for range of motion, functional elbow motion, and elbow clinical function, as well for postoperative complications. Univariate analysis was conducted to detect the differences in outcomes between protocol groups with P<0.01 considered significant. RESULTS: One hundred patients were included in the final analysis, with 17 patients in the liberal group, 50 in the intermediate group, and 33 in the conservative group. There were no differences in patient population (age, sex, fracture type, concomitant nerve palsy, ipsilateral injuries, or physical therapy referrals) between the groups (P>0.01). There were no differences in range of motion, functional motion, or elbow clinical function (P>0.01) between the postoperative protocol groups. There were no postoperative complications (unplanned return to operating room, refracture, need for fixation revision, or infection) in any patient. CONCLUSIONS: There were no differences in postoperative complications or outcomes between the patients in the liberal, intermediate, or conservative protocol groups. In an efficiency-focused era, we conclude that a standardized liberal protocol be considered at a busy orthopaedic center. LEVEL OF EVIDENCE: This study is a level III therapeutic study. It is a retrospective study that compares the outcomes after following 1 of 3 different postoperative protocols.

Open Fractures in Pediatric Orthopaedics-Can Pathways Improve Care? A 1-Year Pre and Postimplementation Analysis.

BACKGROUND: In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our institution we designed and implemented an open fracture pathway with the goal of reducing the time from emergency department (ED) arrival to antibiotic administration. Here we evaluate the success of this pathway, propose improvements in the protocol, and provide a framework for initiation at other institutions. METHODS: We compared a retrospective prepathway cohort with a prospective postpathway cohort for 1-year pre and postpathway implementation. First, we analyzed the number of patients from outside facilities who had received antibiotics before transfer. For patients who had not received antibiotics before arriving at our institution, we reviewed pathway metrics including time from ED arrival to the ordering and administration of antibiotics, whether the correct antibiotic type was selected, and time to surgical debridement. RESULTS: There were 50 patients in the prepathway cohort and 29 in the postpathway cohort. Prepathway 60.5% of transfers (23 of 38) received antibiotics before transfer, whereas post-pathway 90.0% of transfers (18 of 20) received antibiotics ( P =0.032). For patients who had not received antibiotics before arriving at our institution and were included in pathway metric analysis, there were no differences in demographics or fracture characteristics. Time from ED arrival to antibiotic order decreased from 115.3 to 63.5 minutes ( P =0.016). Time from antibiotic order to administration was similar between groups (48.0 vs. 35.7 min, P =0.191), but the overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes ( P =0.004). There were no significant differences in whether the correct antibiotic type was chosen ( P =0.354) or time from ED arrival to surgery ( P =0.783). CONCLUSIONS: This study provides evidence that for pediatric patients presenting with open fractures, a care pathway can successfully decrease the time from ED arrival to antibiotic administration. LEVEL OF EVIDENCE: Therapeutic level III-retrospective comparative study.

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis.

INTRODUCTION: The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions. METHODS: Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention. RESULTS: Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h. CONCLUSIONS: This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO. LEVEL OF EVIDENCE: Level III.

Effects of Therapeutic Ultrasound on Growth Plates: A Systematic Review.

PURPOSE: The aim of this systematic review was to evaluate studies reporting on the effects of therapeutic ultrasound on the physis. SUMMARY OF KEY POINTS: Eight studies were included in the final analysis, all of which were animal studies. At higher doses, studies found skin and bone necrosis and inhibition of growth, while in lower doses some studies found that ultrasound had a transient stimulatory effect on growth, increased thickness of the hypertrophic zone, and increased thickness of the whole growth plate. Overall, experimental evidence in animal models suggests that therapeutic ultrasound, even at low doses, might induce microscopic changes to the histology of the growth plate. CONCLUSION: While we found no reports of growth disturbance in humans, given the histological changes found in animal studies, the current limited literature seems to support the recommendation that the application of therapeutic ultrasound around the physis should be avoided.

Seasonal variability and age-related risk in youth trampoline injuries.

BACKGROUND: The aim of this work was to estimate the difference in severity between musculoskeletal trampoline park injuries (TPIs) and home trampoline injuries (HTI) and identify the factors that might mediate or modify that effect. METHODS: The National Electronic Injury Surveillance System database was used to identify musculoskeletal home trampoline injuries and TPIs in pediatric patients occurring in the 2009-2017 period. Injury mechanism and body region were inductively coded. The effect of TPI on risk of admission was estimated using a doubly robust logistic regression model for confounding adjustment. Adjustments were made for date, age, gender, injury mechanism, and body region. The comparative importance of injury mechanism and location and the effect modification of patient characteristics was explored using likelihood ratio tests. RESULTS: Trampoline park injuries were more likely to result in admission even in the model adjusted for injury mechanism and body region (odds ratio (OR) = 2.12 [1.30, 3.45]). Injuries sustained from falling off the trampoline were associated with significantly fewer hospitalizations (OR = 0.119 [0.029, 0.495]) than injuries from falling while on the trampoline. Patient age significantly modified the effect of setting on risk of admission (P = 0.042). Adolescents demonstrated an increased risk at trampoline parks (15 years old OR = 3.23 [1.38, 7.56]), whereas younger children demonstrated a marginally lower risk (5 years old OR = 0.77 [0.44, 1.35]). CONCLUSIONS: Trampoline park musculoskeletal injuries demonstrate an increased risk of admission even after rigorous adjustment for confounding. Injuries to the proximal limbs were associated with a much higher risk of admission than distal injuries. Adolescents face an increased risk of admission after TPI, underscoring the importance of public health interventions that target this age group.

Entire-spine Magnetic Resonance Imaging Findings and Costs in Children With Presumed Adolescent Idiopathic Scoliosis.

BACKGROUND: Patients with adolescent idiopathic scoliosis (AIS) are commonly monitored for curve progression with spinal radiographs; however, the utility of magnetic resonance imaging (MRI) screening is unclear. The purpose of this study was to assess the findings of screening MRI for patients with a nonsurgical curve size ordered during routine clinical care and compare them with MRI ordered for patients with large curves as part of preoperative screening. METHODS: All consecutive patients with presumed AIS who underwent entire-spine MRI with a presumed diagnosis of idiopathic scoliosis at a single institution between 2017 and 2019 were retrospectively reviewed. Patients were stratified based on MRI indication into the following groups: preoperative evaluation, pain, neurological symptoms, abnormal radiographic curve appearance, rapidly progressive curve, and other. Neural axis abnormalities recorded included concern for tethered spinal cord, syringomyelia, and Chiari malformation. The MRI findings of preoperative patients with large curves were compared with all other patients. The number needed to diagnose (NND) a neurological finding was calculated in patients whose MRIs were ordered during routine clinical care. The amount charged for each patient undergoing entire-spine MRI was determined by review of our institution's Financial Decision Support system. RESULTS: There were 344 patients included in this study with 214 (62%) MRIs performed for preoperative evaluation. Although MRI abnormalities were found in 49% of patients, only 7.0% (24/344) demonstrated neural axis abnormalities with no difference between preoperative and other indications (P=0.37). For patients with nonsurgical curves undergoing MRI due to a complaint of back pain (n=28), there were no neural axis abnormalities, and a lower rate of disk herniation/degenerative changes detected compared with preoperative MRI (3.6% vs. 18%, P=0.06). Among the 15 patients undergoing MRI for a neurological concern, 1 had a neural axis abnormality that required surgical detethering. The NND for MRI to detect a neural axis abnormality that potentially required neurosurgical intervention in nonpreoperative patients with a neurological concern was 34.4. The average cost for MRI was $17,816 (range: $2601 to $22,411) with a total cost of $2,368,439 for nonsurgical curves. CONCLUSIONS: Entire-spine MRI for nonpreoperative indications including pain, abnormal radiographic curve appearance, and rapid curve progression has minimal utility for patients with AIS. For patients with neurological complaints, the NND a potentially treatment-altering finding with MRI is 34.4. LEVEL OF EVIDENCE: Level II-diagnostic.

Can Rapid Progression in Nonambulatory Cerebral Palsy Scoliosis Be Predicted Using Humeral Head Ossification?

BACKGROUND: Patients with cerebral palsy scoliosis (CPS) experience higher complication rates compared with idiopathic scoliosis and often present for surgery with larger curves. Prediction of an inflection point for rapid deformity progression has proven difficult. A proximal humerus-based skeletal maturity staging system (HS) has been recently validated and is commonly visible on the posteroanterior radiograph. The authors hypothesize that this system can be used to identify a period at which CPS may progress rapidly, perhaps facilitating discussion of timely surgical intervention. METHODS: A retrospective review was conducted for nonambulatory pediatric patients with CPS who presented between 2009 and 2018 at our institution. All patients were considered for inclusion regardless of operative or nonoperative management. Patients who were skeletally mature at initial evaluation or had prior spine surgery were excluded. The authors analyzed radiographs in each HS available. Survival was calculated for cutoffs of 60 and 70 degrees (numbers found to increase intraoperative and postoperative complications for CPS). RESULTS: Eighty-six patients with CPS were identified (54 male individuals). Major curves increased significantly between HS 1 and 2 (27.7 to 46.6 degrees, P=0.009) and HS 3 and 4 (53.1 to 67.9 degrees, P=0.023). The proportion of curves ≥70 degrees were significantly different between HS (P<0.001), with the greatest increase between HS 3 and 4 (24% to 51%; ≥70 degrees). The largest drop in the 60/70-degree survival curves was between HS 3 and 4. In a subanalysis, 69% of patients with curves ≥40 degrees but <70 degrees in stage 3 would progress ≥70 degrees by stage 4. CONCLUSIONS: Identifying a period of rapid curve progression may guide surgical planning before CPS curves become large, stiff, and more difficult to fix. Our findings suggest that humeral skeletal maturity staging is a valuable decision-making tool in neuromuscular scoliosis, with the HS 3 to 4 transition representing the time of the greatest risk of progression. Consider a surgical discussion or shortened follow-up interval for patients with CPS with curves ≥40 degrees who are HS 3. LEVEL OF EVIDENCE: Level II.

Risk of Scoliosis Progression in Nonoperatively Treated Adolescent Idiopathic Scoliosis Based on Skeletal Maturity.

BACKGROUND: Hand radiographs for skeletal maturity staging are now frequently used to evaluate remaining growth potential for patients with adolescent idiopathic scoliosis (AIS). Our objective was to create a model predicting a patient's risk of curve progression based on modern treatment standards. METHODS: We retrospectively reviewed all AIS patients presenting with a major curve <50 degrees, available hand radiographs, and complete follow up through skeletal maturity at our institution over a 3-year period. Patients with growth remaining underwent rigid bracing of curves >25 degrees, whereas patients between 10 and 25 degrees were observed. Treatment success was defined as reaching skeletal maturity with a major curve <50 degrees. Four risk categories were identified based on likelihood of curve progression. RESULTS: Of 609 AIS patients (75.4% female) presenting with curves over 10 degrees and reaching skeletal maturity at most recent follow up, 503 (82.6%) had major thoracic curves. 16.3% (82/503) of thoracic curves progressed into surgical treatment range. The highest risk group (Sanders 1 to 6 and curve 40 to 49 degrees, Sanders 1 to 2 and curve 30 to 39) demonstrate a 30% success rate with nonoperative treatment. This constitutes an 111.1 times (95% confidence interval: 47.6 to 250.0, P<0.001) higher risk of progression to surgical range than patients in the lowest risk categories (Sanders 1 to 8 and curve 10 to 19 degrees, Sanders 3 to 8 and curve 20 to 29 degrees, Sanders 5 to 8 and curve 30 to 39 degrees). CONCLUSIONS: Skeletal maturity and curve magnitude have strong predictive value for future curve progression. The results presented here represent a valuable resource for orthopaedic providers regarding a patient's risk of progression and ultimate surgical risk. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

The Majority of Patient-reported Outcome Measures in Pediatric Orthopaedic Research Are Used Without Validation.

BACKGROUND: Given that patient-reported outcome measures (PROMs) are increasingly used to inform clinical decision-making, it is vital that they are validated, reliable, responsive, and appropriate for the population under study. The purpose of this systematic review was to assess the rate of PROM use in the pediatric orthopaedic literature, characterize whether each use was in the PROM-validated demographic, and analyze the association between bibliometric factors and the use of PROMs with incomplete validation. METHODS: The Institute for Scientific Information (ISI) Web of Science database was queried for all clinical pediatric orthopaedic studies from 2014 to 2017. All PROMs were recorded for each study independently by 2 reviewers and cross-referenced with the published orthopaedic literature as of 2017 to determine if the PROM had been validated for the study population. PROMs that had not been validated, had been shown to be invalid, or had conflicting validity studies for use in the population of interest were designated as incompletely validated or used without complete validation. The following covariates were recorded for each study: subspecialty, inclusion of a statistician coauthor, sample size, journal, and the journal impact factor. χ analysis was used to evaluate the association between categorical variables and the use of at least 1 incompletely validated PROM. RESULTS: In total, 1000 articles were screened, yielding 653 studies that met our inclusion criteria. A total of 104/653 (16%) publications-reported PROMs. PROMs were used without complete validation 120/165 (73%) times, and 77/104 (74%) studies used at least 1 PROM without complete validation. The most frequent reasons for incomplete validation were (1) using PROMs that had been validated in adults, but not pediatrics (n=47; 28.5%), and (2) using PROMs that had been designated in the literature as invalid for pediatrics (n=27; 16.4%). The incomplete validation of at least 1 PROM was associated with smaller sample size (P=0.01) and subspecialty (P<0.01). Overall rates of PROM use and the proportion of PROMs used without complete validation were both found to be higher than those previously reported. CONCLUSION: The majority of pediatric orthopaedic studies reporting PROMs used at least 1 PROM without complete validation for their study population. LEVEL OF EVIDENCE: Level IV-systematic review of level I, II, III, and IV studies.

Flexible Intramedullary Nailing of Femoral Shaft Fractures in Children Weighing ≥40 kg: A Systematic Review and Meta-analysis.

BACKGROUND: Pediatric femur fractures are commonly treated with flexible intramedullary nails (FIN). However, there is controversy regarding the effect of patient weight on outcomes and complications. The purpose of this meta-analysis was to review the literature and describe implant choice, analyze complication, and reoperation rates; as well as the report clinical and radiographic outcomes of FIN in pediatric patients weighing ≥40 kg with femoral shaft fractures. METHODS: A systematic review was performed of all retrospective and prospective studies focusing on the use of FIN in heavy children in Medline, Cochrane, and Web of Science databases. Data extraction was performed and summarized using descriptive statistics. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis was performed for complications using pooled data from included studies. RESULTS: The initial search strategy yielded 177 references, and after exclusions, 5 studies were included. The majority of studies were retrospective, and the most commonly used implants in heavier patients were titanium FIN and stainless steel Enders FIN. There were higher rates of radiographic nonunion and malunion, complications, and reoperations for refracture; and nonunion in heavier children treated with FIN. Meta-analysis performed on 4 applicable studies showed the overall complication rate was higher in the heavier patients compared with lighter patients (30.6% vs. 11.1%) with a relative risk of 1.20 [95% confidence interval (CI), 1.02-1.41]. Heavier patients also had higher rates of major complications (relative risk, 1.32; 95% CI, 1.03-1.69) but similar minor complications (relative risk, 1.13; 95% CI, 0.90-1.41). CONCLUSIONS: Heavier children have worse radiographic outcomes and higher complication rates with the use of FIN for femoral shaft fractures. Additional research is needed to determine the effect of FIN material on clinical outcomes in heavier children, and the relationship between weight and other known risk factors for poor outcome in FIN, such as length stability. LEVEL OF EVIDENCE: Level III-systematic review of level-III studies.